Cystic Fibrosis Nursing Care Plan


Nursing Diagnosis

Ineffective airway clearance related to thick mucus secretions and effort and a lot of bad cough.

Goal: Not experiencing aspiration.

  • Shows an effective cough and increased air exchange in the lungs.
  • Auscultation of breath sounds. Note the example of wheezing breath sounds, crackles, rhonchi.
    • Rationale: Some degree of spasm of the bronchial obstruction with airway obstruction and may / not indicated the presence of abnormal breath sounds or crackles eg absence of breath sounds.
  • Perform physiotherapy to issue secret and give the patient a comfortable position, eg, elevation of the head of the bed, sitting on the back of the bed (position semi-Fowler / Fowler).
    • Rationale: head of bed elevation facilitate respiratory function using gravity.
  • Assist clients to dilute sputum, with the collaboration expectorant administration to improve airway clearance.
    • Rationale: Giving expectorants may help thin the secret, that secret is more easily removed.
  • Provide nebulizer with a solution and in accordance with the right tools.
    • Rationale: Nebulization can help spending viscous secretions.
  • Observations clients closely after aerosol therapy and chest physiotherapy to preventaspiration due to many sputum suddenly become watery.
    • Rationale: To prevent aspiration.
  • Provide postural drainage (adjust the area where there is a buildup of mucus) as prescribed to reduce the viscosity of mucus.
    • Rationale: Postural drainage aids in the excretion of mucus is thick.

Nursing Diagnosis
  • Impaired gas exchange related to airway obstruction by nasal obstruction.

Goal: Maintaining adequate oxygenation or ventilation.

  • The patient showed respiratory rate effectively.
  • Free of respiratory distress.
  • Arterial blood gas within the normal range.
Nursing Interventions
  • Maintain a patent airway.
    • Rationale: Preventing complications of respiratory failure.
  • Position the patient to obtain maximum efficiency ventilators, such as a high Fowler’s position or sitting, leaning forward.
    • Rationale: Position Fowler / semi-Fowler can facilitate respiratory function and can reduce airway collapse, dyspnoea, and breath work by using gravity.
  • Monitor vital signs, arterial blood gases (ABGs), and pulse oximetry to detect / prevent hypoxemia.
    • Rationale: increased PaCO2 indicates impending respiratory failure during asthmatic. Tachycardia, dysrhythmias, and changes in BP may indicate systemic hypoxemia effects on cardiac function.
  • Provide supplemental oxygen according to the provisions / requirements. Monitor patients closely for carbon dioxide narcosis due to oxygen is danger of oxygen therapy in patients with chronic lung disease.
    • Rationale: Occurrence / respiratory failure that would require effort dating lifesaving action. Supplemental oxygen administration can fix / prevent worsening hypoxia.
  • Motivation exercise appropriate physical condition of the patient.
    • Rationale: Physical exercise is often effective to clear accumulated lung secretions and to improve endurance exercise capacity before experiencing dyspnea

Nursing Diagnosis
  • Ineffective breathing pattern related to tracheobronchial obstruction.


  • Repairing or maintaining a normal breathing pattern.
  • Patients achieving lung function maximum.
  • Patients showed an effective respiratory frequency with the frequency and depth within the normal range and lungs clear / clean.
  • Patients free of dyspnea, cyanosis, or other signs of respiratory distress.
Nursing Interventions
  • Provide position Fowler or semi-Fowler.
    • Rationale: Position Fowler / semi-Fowler enables lung expansion and ease breathing. Changing position and ambulation improve air charging different lung segments which improves gas diffusion.
  • Teach deep breathing techniques, and or lip breathing or diaphragmatic breathingabdominal exercises when indicated and effective cough.
    • Rationale: to help spending sputum.
  • Observation vital signs (RR or frequency per minute).
    • Rationale: Tachycardia, dysrhythmias, and changes in BP may indicate the effect of systemic hypoxemia pad cardiac function.